Alzheimers disease Management in the home

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Alzheimers disease Management in the home

• Freda Kelley, BSN,RN, CHCE,CDP
• Foundation Management Service, Inc.

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Non-Endorsement of Products

• Approved provider status does not imply
  endorsement by the approved provider, TNA or ANCC
  COA of any commercial products displayed in
  conjunction with an activity.
• Learners are notified when an educational
  activity relates to any product used for a
  purpose other than for which it was approved by
  the Food and Drug Administration.

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Continuing Education

• Requirements for Successful Completion
• Learners must attend the workshop in its
  entirety. Partial credit will not be awarded
• Learners must turn in an evaluation at the end of
  the workshop in order to receive a certificate of
  successful completion.

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Conflicts of Interest

• Learners will be informed of any influencing
  financial relationships or lack thereof
• Commercial support Learners will be made fully
  aware of the nature of an commercial support
  related to this educational activity.

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Learning Objectives

• Participant will
• 1. Identify the progressive steps being made with
  CMS in parts of our country in home care
  interpretation of medical policy regarding
  Alzheimers disease care.
• 2. Describe Alzheimers disease behaviors that
  exhaust the caregiver and may qualify the patient
  for the Medicare home care teaching and training
  benefit.
• 3. Identify common behaviors associated with
  Alzheimers disease patients, and how to record,
  report and request appropriate intervention.
• 4. List strategies of the 4-S non-pharmacological
  steps to manage AD
• 5. Identify the benefits of rehabilitation
  therapy in the home care setting and the
  difference between traditional rehab and the
  Alzheimers disease approach to therapy

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Impact of Alzheimers Disease

• The leading cause of dementia among the elderly
• Currently every 71 seconds, an American develops
  Alzheimers
• By mid-century an American will develop AD every
  33 seconds
• AD and other dementias cost the US more than 148
  billion annually in Medicaid and Medicare
  services and in indirect cost to businesses that
  employ AD and dementia caregivers
• Several promising drugs currently in clinical
  trials could be disease-modifying or provide
  symptomatic relief
• Increase in AD research funding is critical in
  forestalling both the loss of life and the
  financial burden on the nation

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Impact of Alzheimers Disease

• In-home support for families dealing with AD is
  minimal
• 7 of 10 people with AD live at home
• 75 of care of people with AD is provided by
  family and friends
• 80 of caregivers experience high levels of
  stress
• 50 of caregivers experience depression

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Impact of Alzheimers Disease

• 5.2 million Americans (200,000 are under age 65)
• Number is increasing annually as the population
  continues to age - expected to double by 2020
• Burden on families and the health care system
  will be substantial as 1 out of every 8 baby
  boomers develops the disease

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Times do change!

• September 25, 2001 Transmittal AB-01-138
• Subject Medical Review of Services for Patients
  with Dementia
• Contractors may not install edits that result in
  the automatic denial of services based solely on
  the ICD-9 codes for dementia.

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Times continue to change!

• April 2002, Mr. Scully of CMS released the
  following statement
• CMS believes that certain therapies can be
  helpful in slowing a beneficiaries decline.

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2005 Local Coverage Determination from CMS

• Contractor Palmetto GBA
• LCD ID Number - L19817
• LCD Title
• Home Health Skilled Nursing Care Teaching and
  Training Alzheimers Disease and Behavioral
  Disturbances
• Original Determination Effective Date - 10/24/2005

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Policy Addresses Behavior Disturbances

• Behavioral disturbances often complicate the
  medical management of beneficiaries with
  Alzheimers disease. At baseline many individuals
  with Alzheimers disease manifest activity
  limitations in such domains as communication and
  self-care. The occurrence of behavioral
  disturbances, if not addressed in a comprehensive
  and systematic manner, may further compromise the
  activity limitations present at
  baseline-resulting in sub-optimal clinical
  outcomes.

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Why behavior disturbances?

• Primary treatment of demented persons
• Highly prevalent during course of disease
• Important factor influencing family decision to
  choose alternate care placement
• Agitated behaviors do not serve the interest of
  the patient
• Agitated behaviors adversely affect others
  efforts to help

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Behaviors are difficult to assess

• Unable to verbalize emotions
• Unable to give reasons for behavior
• Caregiver is often unable to express

Observation and reporting is the KEY
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Inside the Human Brain
The Brain in Action
Hearing Words Speaking Words Seeing
Words Thinking about Words
Different mental activities take place in
different parts of the brain. Positron emission
tomography (PET) scans can measure this activity.
Chemicals tagged with a tracer light up
activated regions shown in red and yellow.
Slide 13
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The truth is

• We must make caregivers/clinicians aware of
• What constitutes behavioral disturbances
• How to report them accurately
• How to receive appropriate assistance and
  intervention

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What is a behavioral disturbance

• Sleeping too much
• Not sleeping
• Eating too much
• Not eating
• Not bathing
• Pacing
• Wandering
• Agitation
• Not doing anything
• Hoarding

• Crying
• Worrying
• Hallucinations
• Delusions
• Illusions
• Paranoia
• Dressing inappropriately
• Repetitive behavior
• And more.

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2005 Local Coverage Determination (LCD)

• Each behavioral disturbance should be fully
  characterized
• What is the behavior?
• What is the frequency?
• Is there a triggering event?
• When does it occur?
• Where does it occur?
• Who is involved?
• Are there other possible explanations?
• What are the consequences of the behavior?
• What interventions have been successful in the
  past?
• What other techniques or interventions can be
  used?

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Mnemonic.I-T-S-O-V-E-R

• I - Identify what is the problem behavior?
• T Timing - when does it happen?
• S Surroundings - where does it happen?
• O - Others involved - who else is involved?
• V - Very troubling - how dangerous is it?
• E Evaluation what else could cause it?
• R- Recommend How do I respond?

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Stages of AD

• Preclinical
• Mild
• Moderate
• Severe
• End Stage

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AD and the BrainPreclinical AD

• Signs of AD are first noticed in the entorhinal
  cortex, then proceed to the hippocampus
• Affected regions begin to shrink as nerve cells
  dies
• Changes can begin 10-20 years before symptoms
  appear
• Memory loss is the first sign of AD
• Estimated duration of FAST stage 1 in AD is15
  years

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Stages of ADMild

• Forgetfulness, unable to learn new information
• Difficulty managing finances, planning meals,
  taking medication on schedule
• Depression symptoms
• Still able to do most activities, drive car
• Gets lost going to familiar places
• Estimated duration of FAST stage 2-4 is 7 to 9
  years

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Stages of ADModerate

• Forgetfulness extends to forgetting old facts
• -Continually repeats stories -Makes up stories
  to fill gaps
• Difficulty performing tasks
• -Following written notes -Using the shower and
  toilet
• Agitation, behavioral symptoms common
• -Restlessness, repetitive movements -Wandering
• -Paranoia, delusions, hallucinations
• Deficits in intellect and reasoning
• -poor judgment, forgets manners
• Concern for appearance, hygiene, and sleep become
  more noticeable
• Estimated duration of FAST stage 5-6 a-e is18 mo
  to 2 years

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Stages of ADSevere

• May groan, scream, mumble, or speak gibberish
• Behavioral symptoms common
• - refuses to eat
• - inappropriately cries out
• Failure to recognize family or faces
• Difficulty with all essential ADLs
• Estimated duration of FAST stage 7a-f is 12 to18
  months

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Teaching and Training

• Medicare home health beneficiaries with
  Alzheimers disease and behavioral disturbances
  could be part of a unique beneficiary-centered
  plan directed at teaching the family or caregiver
  how to manage the behavioral disturbance.

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CMS Scenario 1

• A beneficiary with moderate Alzheimers disease
  is unable to bathe and groom herself. The family
  describes the beneficiary as uncooperative. The
  primary caregiver is a daughter who is trying her
  best to provide assistance and feels frustrated
  by the situation, but would like to learn how to
  work with her mother and keep her at home. The
  beneficiarys physician has determined that the
  uncooperativeness is the result of receptive
  language impairment, perceptual
  misinterpretations, and impairments in learned
  motor skills all due to the Alzheimers
  disease. The teaching services are reasonable and
  necessary for the beneficiarys treatment, and to
  maintain proper hygiene and skin care.

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Teaching and Training

• Teach daughter about the disease
• Teach about amnesia, aphasia, apraxia, and
  agnosia and how each symptom can influence a
  level of cooperativeness or uncooperativeness
• Teach how to simplify the environment
• Teach how to make the bathroom safe and
  comfortable

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Teaching and training.

• Reduce clutter, reduce noise, get organized ahead
  of time, appropriate temperature of the room
• Keep communication simple
• Use bridging or chaining techniques
• Safe transfer techniques
• Depth perception techniques
• Creative in approach

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More teaching

• Attitude and tone is everything and if the
  caregiver is tired.ooops!
• Demonstration is a great way to learn
• Home care allows a relationship to be developed
  and adult education methods to be utilized
• The person with dementia may not remember your
  name, but they WILL remember how you make them
  FEEL!

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Occupational Therapy

• Supporting the Local Medical Review policy for
  Alzheimers disease care in the home setting is
  the American Occupational Therapy Association
  Practice Guidelines for Adults with Alzheimers
  Disease.

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Research shows

• Continuation of activity is critical to limiting
  behavioral problems associated with AD
• Performance of ADLs often can be improved by
  modifying task requirements and adapting the
  environment
• OT helps people regain, develop and build skills
  that are essential for ADL
• This ability can reduce negative behaviors and
  alleviate caregiver stress!

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Joseph Isaacs, executive director of AOTA stated
May 14, 2005

• When an occupational therapist addresses
  cognitive problems, memory, environment and
  family issues, it can mean the difference between
  acceptance and adjustment or continued and
  growing crisis for families and the Alzheimer's
  patients themselves. Occupational therapy
  intervention can help slow the decline of
  patients and even prevent placement in nursing
  homes.

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Therapy with the AD Patient

• Traditional Rehab
• Restore
• Assess deficits
• Remediate deficits
• Adapt patient to environment
• Teach patient
• Teach new tasks

• Alzheimers Approach
• Compensate and adapt
• Assess abilities
• Facilitate strengths
• Adapt environment to patient
• Teach caregiver
• Adapt task to patient

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CMS Scenario 2

• A physician has ordered skilled nursing care for
  teaching behavioral techniques to a care giving
  niece of a patient with moderate Alzheimers
  disease to gain the patients cooperation during
  mealtime. Due to the patients wandering
  behaviors, she will not stay seated for a meal
  and the niece believes she is trying to be
  difficult. The patient has been gradually losing
  weight (10 pounds over 2 months) and she is less
  coordinated with her utensils due to her
  underlying dementia as well as a new onset
  tremor. The teaching services are reasonable and
  necessary for the patients treatment and
  adequate nutritional intake.

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CMS says

• While the ultimate goal of clinical interventions
  addressing persons with Alzheimer's disease and
  behavioral disturbances is an improvement in
  function, it is anticipated that the
  beneficiaries served under this policy will have
  diverse clinical presentations and environmental
  factors.

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Home Health Teaching Interventions

• Teach primary symptoms of AD, amnesia, aphasia,
  apraxia, agnosia and how each of these symptoms
  can influence the patients functional ability
  and level of cooperativeness at mealtime
• Explore strategies to decrease wandering at
  mealtimetoilet before meals, take for a walk
  before meals, wait to seat until the meal is on
  the table, position the patient in a comfortable
  place
• Reduce clutter, reduce need for utensils, add
  finger foods
• Give one food at a time, limit verbal cuing to
  one step at a time.
• Use bridging or chaining techniques

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Home Health Teaching Interventions

• Turn off television or radio
• Consider fortified supplements between meals
• Begin meal with favorite foods
• Evaluate, consider adaptive equipment or
  Occupational Therapy referral
• Cut or prepare food ready for easy intake
• Look for signs of poor dental hygiene
• Look for signs of difficulty swallowingpocketing
  foods in cheeks.

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Home Health Teaching Interventions

• Assess medication regimen
• Assess bowel habits
• Monitor weight
• Have someone else eat at the same time so that
  behavior modeling can potentially occur
• Assess for psychiatric symptoms such as
  depression, paranoid delusions that could result
  in a decreased food and fluid intake and notify
  the physician.

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Basic Principles

• The 4 S Approach
• Kevin Gray, MD

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The 4- S Approach

• Safety
• Serenity

• Structure
• Sanity

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Safety

• More than child-proofing medications, lethal
  poisons, firearms, matches, sharps, power
  tools, gasoline for the lawn mower.
• Hot water heater temperatures lowered
• Secure locks - wandering
• ID bracelets
• Kitchen junk drawer
• Mail
• Driving
• Bathroom door locks

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Serenity

• God grant me the serenity to accept the things I
  cannot change the courage to change the things I
  can and the wisdom to know the difference.

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Serenity

• Serenity begins with a deliberate and practiced
  management of affect on the part of the
  caregiver.
• Communicate affection, provide reassurance and
  use simple distractions when tensions rise
• Tapping into remote memories via reminiscence can
  be helpful

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Structure

• Make the environment regular and predictable and
  familiar as possible
• Patience is the key and allows new habits
• Establishing routine is critical

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Sanity

• Preserving caregiver sanity allows for optimal
  patient care!
• Caregiver burnout is a major determinate of
  nursing home placement.
• Caregivers struggle with the added burden of
  responsibility and the loss of the relationship
  of the loved one they are caring for.
• Social isolation occurs for the caregiver.

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Sanity

• Criticism of family or clinicians may undermine
  sanity of caregiver.
• Helping caregiver set reasonable limits and
  goals, along with reminders that rest is
  required.
• Caregivers should remind and assist rather than
  take over and foster dependency.

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Welcome to 21st Century Home Care

• Home care offers the incredible opportunity to
  provide medically appropriate, evidence-based,
  therapeutic teaching and training to the millions
  of home caregivers who are providing care and
  support to loved one with Alzheimers disease.

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Learning Objectives

• Participant will
• 1. Identify the progressive steps being made with
  CMS in parts of our country in home care
  interpretation of medical policy regarding
  Alzheimers disease care.
• 2. Describe Alzheimers disease behaviors that
  exhaust the caregiver and may qualify the patient
  for the Medicare home care teaching and training
  benefit.
• 3. Identify common behaviors associated with
  Alzheimers disease patients, and how to record,
  report and request appropriate intervention.
• 4. List strategies of the 4-S non-pharmacological
  steps to manage AD
• 5. Identify the benefits of rehabilitation
  therapy in the home care setting and the
  difference between traditional rehab and the
  Alzheimers disease approach to therapy

49
References

• www.CMS.gov
• www.alz.org
• www.alzfdn.org
• Barry Reisberg, MD
• Kevin Gray, MD
• International Conference on Alzheimers Disease
  2008

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Research Update

• Does one protein mechanism underlie the
  development of plaques and tangles?
• Which risk factors most accurately predict the
  development of dementia?
• How does the communication style of caregivers
  affect the quality of life of individuals with
  Alzheimers disease (AD)?
• The Alzheimers Association 2008 International
  Conference on
• Alzheimers Disease (ICAD), held July 2631in
  Chicago, sought to
• answer these and other questions in diverse areas
  ranging from drug
• trials to genetics, neuroimaging, diagnosis and
  social and behavioral
• issues in AD and other forms of Dementia.

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Highlights of Research FindingsInternational
Conference on Alzheimers Disease

• Disease mechanisms and therapeutic strategies
• Biomarkers
• Risk factors and prevention
• Communication style and quality of life
• Research is moving on all fronts and in
  unexpected directions.
• Sam Gandy, MD, PhD of the Mount Sinai School of
  Medicine in New York, New York

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Therapeutic Strategies

• Treatment with intravenous immunoglobulin (IVIg)
  over nine months resulted in statistically
  significant improvements on both cognitive and
  global clinical measures in a Phase II trial of
  individuals with mild-to-moderate AD.
• On the market for more than 25 years as a
  treatment for
• autoimmune diseases, IVIg contains antibodies
  that bind to the beta-amyloid aggregates thought
  to be central to AD.
• A Phase III clinical trial is under way. If final
  trail is successful, this may be available 2012

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Therapeutic Strategies

• In a study recently reported, Dimebon
  (Medivation) improved cognition and memory,
  activities of daily living, and behavior in a
  one-year placebo-controlled trial of patients
  with mild to moderate Alzheimer's. At ICAD 2008,
  Jeffrey L. Cummings, M.D., the Augustus S. Rose
  Professor of Neurology, and Professor of
  Psychiatry and Biobehavioral Sciences, at UCLA,
  and colleagues reported on an open-label
  extension of the trial to 18 months.
• Dimebon was well-tolerated through 18 months.
  Adverse events that occurred more often with
  dimebon compared to placebo were dry mouth,
  sweating and depressed mood/sadness.
• "Dimebon appears to work through a mechanism of
  action that is distinct from currently marketed
  Alzheimer's drugs. Dimebon improves impaired
  mitochondrial function. Mitochondria are the
  central energy source of all cells and impaired
  mitochondrial function may play a significant
  role in the loss of brain cell function in
  Alzheimer's," Cummings added.

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Rember (methylthioninium chloride)

• The first medication directly to attack the
  tangles that develop in the brains of those
  affected with AD
• The tangles, made up of a protein know as tau,
  form inside nerve cells in the brain and impair
  concentration and memory. The tangles first
  destroy the nerve cells linked to memory and then
  destroy neurons in other parts of the brain as
  the disease progresses
• If the final trial is successful, Rember could be
  available by 2012

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Therapeutic Strategies - Rember

• A 24-week, Phase II trial of methylthioninium
  chloride (MTC) followed by a 60-week extension
  trial found that at 24 weeks MTC produced a
  significant improvement relative to placebo.
• The compound stabilized the progression of AD
  over 50 weeks in both mild and moderate AD.
• MTC, which dates from the 1930s, inhibits the
  aggregation of tau, the protein that forms the
  neurofibrillary tangles of AD. Among its earlier
  uses, it was used as an antibiotic.
• A Phase III trial is planned.

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Challenges with Research

• Slow decline in placebo groups in clinical trials
• Phase III clinical trials carry a high risk of
  failure because of the potential of larger sample
  sizes and longer trial durations to produce
  results different from the smaller shorter Phase
  II trials
• Physical changes to the brain in AD begin years
  before clinical symptoms such as memory loss
  develop
• Biomarkers would enable researchers to set
  changes as evidence of a clinical trials success

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Challenges with Research

• There is a movement to identify the disease
• earlier and earlier, and we need pre-symptomatic
• biomarkers to do this. A consistent theme has
• emerged of early detection for early
  intervention.
• Ronald Petersen, M.D., of the Mayo Clinic,
  Rochester,
• Minnesota, United States.

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Timely Diagnosis Will Provide

• A helpful framework for understanding symptoms
• An opportunity to build the right medical team
• Access to existing medications
• An opportunity to participate in studies of
  experimental drugs or other treatments
• Access to programs and service
• Enhanced safety and security
• An opportunity to plan for the future

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National Memory Screening Day

• Alzheimer's Foundation of AmericaNational Memory
  Screening Day6th Annual Event
• Save the Date
• November 18, 2008
• National Memory Screening Day is a collaborative
  effort spearheaded by the Alzheimer's Foundation
  of America to promote early detection of
  Alzheimer's disease and related illnesses, and to
  encourage appropriate intervention.
• AFA carries out this event in collaboration with
  organizations and healthcare professionals across
  the U.S.bringing them together for care.
  Participating sites offer free confidential
  memory screenings, as well as follow up resources
  and educational materials to those concerned
  about memory loss. Together, we hope to improve
  quality of life.

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Alzheimers Association Memory Walk

• 32 Walks in Texas
• First in 2008 Katy, Texas September 9
• Still coming College Station and Dallas, TX
• November 15
• Not too late to join a team or donate

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Risk Factors and Prevention

• Early studies have shown consistent findings of
  physical and mental inactivity associated with
  higher risk of cognitive decline
• A study of 422 healthy people over the age of 60,
• showed that those with metabolic syndrome had an
  almost 35 higher level of cognitive compromise
  than those without metabolic syndrome

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Communication Style and Quality of Life

• Elderspeak defined as overly caring,
  controlling and infantilizing communication by
  caregivers
• Research shows there is increased resistance to
  care by nursing home resident with dementia
• Probability of resistance to care (RTC) was .55
  with elderspeak and .26 with normal communication
• Other communication studies are also being
  conducted

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Summary

• Alzheimers Disease is impacting our world, our
  nation, our neighborhoods, our workplaceour
  healthcare system.
• We must be alert, attentive and pro-active in the
  course of this disease.
• Thank you for your time and attention.

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Memories.

• My Mama and Daddy - 1935

• My Granddaughter - 2008